Utilizing a Caring-based Nursing Model in an Interdepartmental Setting to Improve
Patient Satisfaction
Pamela B. Dudkiewicz, DNP, ARNP, BC, AOCNP, University of Miami Sylvester Comprehensive Cancer Center, Florida
Atlantic University
Abstract
Caring is viewed as the essence of nursing. However caring is not a phenomenon exclusive to
nurses. Hospitalized patients encounter numerous people in addition to nurses and each role
and individual make an impact upon the care of the patient. These encounters can dramatically
influence the level of satisfaction a patient feels about their hospital experience. The purpose of
this study was to determine if implementing an interdepartmental caring-based approach based
on Jean Watsons theory of human caring could have a positive effect on patient satisfaction. It
was determined that satisfaction levels did improve significantly following a caring-based
intervention.
Keywords: caring model, interdepartmental,
patient satisfaction, Jean Watsons theory of
human caring
Introduction
Caring is viewed throughout the literature
as the essence of nursing, and most nurses
understand the impact that their caring intention
and practice has on patients (Henderson et al.,
2007). Service employees such as phlebotomy,
housekeeping, and dietary and administrative/
clerical staff, are made up of caring individuals;
however they may not fully grasp the impact or
the significance they have on the patients overall
perception of being cared for. During a
hospitalization, a patient encounters many other
disciplines as well as other service departments,
in addition to nursing, throughout their hospital
stay. Each interaction a patient has can
contribute to a positive or negative experience for
the patient, no matter how small or insignificant
these moments may seem. How a patient is
perceived to be cared for is directly related to
how satisfied they are with the whole patient
experience (Sofaer & Firminger, 2005). The
literature suggests that implementing a caring-
based model could improve staffs perception of
their role as an integral part of the patients care
experience and improving staffs satisfaction in
their job, which could in turn enhance and
improve patient satisfaction (Amendolair, 2012;
Stanowski, 2009; Suliman, Welmann, Omer, &
Thomas, 2009).
Significance
The healthcare culture we live in today has
been overloaded with increased demands for
quantity and efficiency as well as for production
and outcomes, causing increased stress on
practitioners and staff within the healthcare
arena. This has the potential to create more and
more distance between staff and the patients
(Watson, 2009a). This distance can be reflected
in the patients satisfaction of the healthcare
experience. The patients expectation of caring
and the caring that is actually received is
30 International Journal for Human Caring
Literature Review
A contemporary measure of quality care has
been attributed to patient satisfaction (Green &
Davis, 2005), and the measurement of the
patient experience has become increasingly
more important (Doyle, Reed, Woodcock, & Bell,
2010). Not only is patient satisfaction an
important indicator of quality care, the financial
success of a healthcare institution lies greatly in
patient satisfaction (Dingman et al., 1999). In
todays day and age with healthcare reform and
conveyed as patient satisfaction (Dingman,
the implementation of the Affordable Care Act
Williams, Fosbinder, & Warnick, 1999).
(ACA), patient satisfaction is a very important
Caring behaviors, according to Dingman et al.
measure that will be used to calculate Medicare
(1999), significantly impact patient satisfaction.
reimbursement rates (Nissley, 2012).
Factors that contribute to patient satisfaction
The human factor is the most influential
include responsiveness, friendliness, empathy,
component of patient satisfaction, according to
courtesy, feeling cared for and about (Sofaer &
J. D. Power and Associates (2012), especially
Firminger, 2005); and these caring behaviors
service-related communications between patients
can and should be expressed by everyone within
and hospital staff. Caring behaviors or caring
the healthcare setting. The purpose of this study
from the staff, as it pertains to patient
was to determine if the implementation of an
satisfaction, is seen throughout the literature,
interdepartmental caring-based model could
although the staff in the majority of the
have a positive effect on patient satisfaction.
publications refers mostly to the nursing staff
(Baldursdottir & Jonsdottir, 2002; Johansson,
Theoretical Framework
Oleni, & Fridlund, 2002; Yeakel, Maljanian,
Jean Watsons theory of human caring is
Bohannon, & Coulombe, 2003; Larrabee et al.,
the theoretical basis for this study. Her theory
2004; Schmidt, 2004; Liu, Mok, & Wong, 2005).
focuses on the caring relationships among
However, caring behaviors are not reserved
humans and the deep experiences of life
exclusively for nurses. During a hospitalization,
(Suliman, Welmann, Omer, & Thomas, 2009).
patients encounter many people, from several
According to Suliman et al. (2009), this theory
different departments, many of whom are not
suggests that caring is a different way of being
nurses but are actually vital members of the
human, present, attentive, conscious, and
hospital staff and play an important role in the
intentional (p. 293). Watsons theory
overall patient experience. Otani et al. (2009)
encompasses three major elements or concepts;
reported that the care of the staff was found to be
the ten carative factors which have evolved to
the most influential attribute of patient satisfaction
clinical caritas processes, the caring occasion/
followed by the patients experience with nursing
caring moment, and the transpersonal caring
care. This reinforces the point that caring can
relationship (Cara, 2003). The broader model of
and is seen across departmental lines and the
caring science and philosophy of caring-healing
vital role it plays in regard to patient satisfaction.
is now being used more frequently as a
Caring behaviors are not limited to only nursing;
philosophical and ethical guide for all healthcare
they can be demonstrated across departmental
professionals and staff (Graber, 2009).
boundaries.
Implementing a caring-based model has been
Healthcare organizations have been recently
identified as an important way to convey staff
called to transform and refocus the culture of
roles, values, and knowledge to the patients as
their organization to more person-centered,
well as to improve communication to and among
caring-based values from traditional bureaucratic
the interdisciplinary staff and departments (Bent
values (Pross, Hilton, Boykin, & Thomas, 2011).
et al., 2005). A caring-based theory, according
Satisfied employees influence productivity as
to Bent et al. (2005), has the potential to better
well as quality of work, resulting in better
meet the needs of patients by creating a caring
outcomes and increased patient satisfaction
community in which individuals, groups, and
(Nikic, Arandjelovic, Nikolic, & Stankovic, 2008;
systems relate in ways that represent caring
Stanowski, 2009). Working in a caring
as a whole.
environment can enable one to find meaning in
their work and can facilitate improved job
satisfaction, staff engagement, and consequently

more effectiveness in ones role (Amendolair,
2012). According to Press Ganeys research,
there is a direct correlation between
employee satisfaction and patient satisfaction
(Stanowski, 2009). Satisfied employees,
according to Stanowski (2009), provide better
care resulting in better outcomes and increased
patient satisfaction.
Patients perceptions of caring are influenced
by the caring behaviors they received during their
healthcare experience (Dingman, 1999). Caring
about the patient is as important to a patients
well-being as providing care for the patient
(Tonges & Ray, 2011). Implementation of caring-
based models has had a positive impact on the
work environment, nurse and patient satisfaction,
and patient outcomes (Winsett & Hauck, 2011).
The literature supports that instituting a
caring-based model and educating the
interdepartmental staff regarding caring
behaviors would increase staffs knowledge
regarding behaviors which are important to the
patient, as well as increase the staffs satisfaction
of their job by empowering them to actively take
part in advancing the patients well-being and
thereby positively improving patient satisfaction.
Methods
The Caring Behavior Assessment (CBA) tool
was used and modified slightly with permission
from the authors, Sherill Cronin and Barbara Lee.
The CBA tool was developed in 1988 and is
made up of 63 caring behaviors based on
Watsons theory of human caring. The behaviors
are grouped into 7 subscales, loosely
corresponding to Watsons 10 caritas processes
(Watson, 2009b). The tool was utilized to identify
behaviors of nurses that patients perceived as
caring and used a 5-point Likert scale (5 = much
importance to 1 = little importance) (Watson,
2009b). For the purpose of this study,
modifications were made addressing the same
63 nurse caring behaviors, but instead of
focusing on the importance each behavior held to
the patient, the primary focus was on how well
each behavior was demonstrated by the nurse or
the staff as perceived by the patient, using the
5-point scale (5 = exceeds behavior to 1 = lacked
behavior). In keeping with Cronin and Lees
original focus of importance, participants were
asked to list 3 of the 63 behaviors that were most
important to them. Finally, addressing the
satisfaction outcome, the participant was asked
to rate their overall satisfaction of their hospital
stay on a 5-point scale (5 = very satisfied to
1 = not satisfied).
This study was submitted to the Human
Subject Research Office, and an institutional
review board (IRB) designee reviewed the study
design and determined that it did not constitute
human subject research; therefore IRB review
Utilizing a Caring-based Nursing Model in an Interdepartmental Setting to Improve Patient Satisfaction
and oversight was unnecessary. Two groups of
patients were randomly selected. Both groups
included patients who had been admitted for at
least 24 hours, were pending discharge within
24 hours, and spoke English. Identified patients
were then informed about the project and were
asked if they would be willing to fill out a
questionnaire. The first group included 20
participants prior to the intervention, and the
second group included 20 participants 1 month
after the intervention.
The intervention consisted of 11, 40 to 45
minute educational in-services to the in-patient
nursing staff as well as 4 other departments that
service the in-patient unit (phlebotomy, dietary,
environmental, and patient access/secretarial
staff). Approximately 80% of the staff from each
of these departments attended the in-services.
The in-services included a PowerPoint
presentation focusing on caring, consequences
of caring and non-caring behaviors, an overview
of Jean Watsons theory, and concluded with a
short video clip titled The Human Connection to
Patient Care. During the presentation, there was
an opportunity for the group to give and receive
care from each other by providing each other
quick shoulder and neck massages. This
intervention demonstrated that caring for a
person and receiving care from a person are
mutually beneficial and that both acts create
meaning and enjoyment.
Data Collection
Two convenience samples were collected,
one sample pre intervention and one sample
post intervention. Inclusion criteria were the
ability to speak English, having been in the
hospital no less than 24 hours, and pending
discharge within 24 hours. After the project
was explained to the patient, the completed
questionnaire served as their consent.
The setting for data collection took place
on the in-patient unit of a comprehensive
cancer center in South Florida. This unit
accommodates patients for medical, surgical,
and radiation oncology. Collection occurred
over a 4-week period for both the pre and
post groups. The post intervention group data
collection began 1 month following the
educational in-service.
Data Analysis
Data was analyzed by independent t-Test
using SPSS comparing the two groups (pre and
post intervention). Mean values and standard
deviations for each item were calculated to
identify the degree to which each caring behavior
was met, as perceived by the patient. Overall
satisfaction levels were analyzed and calculated
in the same way to identify the extent to which
satisfaction levels changed. Finally, the 7
subscales were evaluated in order to gauge the
level of change that was attained in each area.
Results
Description of the sample.
There were a total of 40 participants that
completed the CBA questionnaire, 20 before
the intervention and 20 after the intervention
(Table 1). The populations in both groups were
fairly similar. Males outnumbered females in both
groups 60% (n = 12) in the pre group and 65%
(n = 13) in the post group. The pre group was
slightly younger than the post group with the
mean age of 47 (SD = 15.5) years and 53 (SD =
15.3) years respectively. The majority of patients
in both groups were married 55% (n = 11) in the
pre group and 45% (n = 9) in the post group and
Hispanic 40% (n = 8) in both groups. In respect
to education level, 70% (n = 14) in both groups
had at least 1-2 years of college education.
These patients were not hospital nave with 45%
(n = 9) in both groups having at least 5 prior
hospitalizations over the past 5 years and the
mean hospital stay during their current admission
was 6 (SD = 11.7) in the pre group and 7.5
(SD = 9.1) in the post group.
Outcomes
The main outcome of this study was
assessing the patients overall satisfaction level
of their hospital stay as measured by improved
satisfaction scores on the post intervention
questionnaire. The satisfaction level had a
statistically significant (t(38) = -2.61, p = 0.013)
improvement after the intervention (M = 4.7,
SD = .44) as compared to prior to the
intervention (M = 4.1, SD = 1.02). The total CBA
scores were also analyzed to determine if there
were any improvements in the scores post
intervention. The pre intervention CBA scores
(M = 249.15, SD = 56.27) did improve post
intervention (M = 278.65, SD = 34.24), although
it was not statistically significant (t(38) = -2.003,
p = 0.52.
The behaviors that the patients reported were
most important to them were consistent in both
groups. The pre intervention group reported that
the 3 most important behaviors, out of the 63,
were know what theyre doing (30%), treat me
as an individual (25%), and give my treatments
and medications on time (25%). The post
intervention group reported that the behaviors
know what theyre doing (30%), treat me as an
individual (20%), and give my pain medications
when I need them (20%), were most important
to them. These findings were consistent with the
study by Suliman, Welmann, Omer, and Thomas
(2009), which ranked these behaviors among the
top 10 out of the stated 63, as most important
behaviors to the patient.
2014, Vol. 18, No. 4 31
Utilizing a Caring-based Nursing Model in an Interdepartmental Setting to Improve Patient Satisfaction
Table 1.
Description of the Sample Groups
Sex
Age
Marital Status
Ethnicity
Education Level
Prior Hospitalization in Past 5 Years
Length of Current Stay
The subscales of the CBA demonstrated
improvement across all 7 subscales, although
only subscale 2 (helping/trust) and subscale 6
(human needs assistance) were statistically
significant; t(38) = -2.76, p = 0.009 and t(38) = -2.35,
p = 0.024, respectively. Although all subscales
are important, subscale 2 is essential because
developing trust with the patient is crucial in
order to allow them to truly accept and benefit
from the care that is being given (Baird, 2013).
When a patient has a diagnosis of cancer, they
are made aware of the importance of getting their
treatments on schedule in order to achieve the
best outcomes possible. Subscale 6 was an
important subscale for this population as this
subscale included one of the behaviors most
important to the participants, give my treatments
and medication on time. One could hypothesize
that this behavior, if not met, could increase
anxiety in the patient and subsequently lower
their satisfaction level. The fact that this subscale
was significantly improved supported this
hypothesized connection.
The overall outcome for this study
demonstrated that the degree to which the
caring behaviors were met improved following
the interdepartmental educational in-service
intervention. This improvement was seen in the
32 International Journal for Human Caring
Pre-intervention
Male - 60% (n = 12)
Female - 40% (n = 8)
24-80 (M = 47)
55% < 50 (n = 11)
Single - 30% (n = 6)
Married - 55% (n = 11)
Divorced/Separated - 15% (3)
Hispanic - 40% (n = 8)
Caucasian - 35% (n = 7)
Black - 15% (n = 3)
Other - 10% (n = 2)
< 8 grade - 10% (n = 2)
9-12 grade - 20% (n = 4)
1-2 years college - 30% (n = 6)
3-4 years college - 20% (n = 4)
> 5 years college - 20% (n = 4)
< 5 admissions - 55% (n = 11)
> 5 admissions - 45% (9)
1-55 days (M = 6)
45% > 4 days (n = 9)
scores of the CBA questionnaire overall and in
the 7 subscales. It was appreciated in the top
3 behaviors that were most important to the
patient as well as a statistically significant
improvement in the satisfaction levels of the
patients post intervention.
Discussion
The results of this study serve as evidence
that implementing a caring-based model across
departmental lines within an institution produces
statistically significant improvements in patient
satisfaction as measured by improved
satisfaction scores on a questionnaire. These
findings complement the conclusions of Dingman
et al. (1999), which spoke to the influence that
implementing a caring model throughout the
organization has on patient satisfaction. This
study demonstrated that broadening the caring
intervention to even four departments, in addition
to the nursing staff on the in-patient unit,
produced a favorable outcome. Implementing
this project on a broader scale throughout the
institution with regular reinforcements of the
caring philosophy and the caring model through
intermittent in-services and annual reviews
has the potential to produce even more
robust outcomes.
Post-intervention
Male - 65% (n = 13)
Female - 35% (n = 7)
23-76 (M = 53)
70% > 50 (n = 14)
Single - 20% (n = 4)
Married - 45% (n = 9)
Divorced/Separated - 35% (n = 7)
Hispanic - 40% (n = 8)
Caucasian - 35% (n = 7)
Black - 5% (n = 1)
Other - 20% (n = 4)
< 8 grade - 5% (n = 1)
9-12 grade - 25% (n = 5)
1-2 years college - 10% (n = 2)
3-4 years college - 15% (n = 3)
> 5 years college - 45% (n = 9)
< 5 admissions - 55% (n = 11)
> 5 admissions - 45% (n = 9)
2-37 days (M = 7.5)
60% > 4 days
Nurses have been identified as working on
the forefront of patient care according to the
Institute of Medicine (2010) and play a vital role
in making change and improving health services.
Nurses are rising to the challenge (Wilson,
Whitaker, & Whitford, 2012). Implementing a
caring-based model across departmental lines
provides an opportunity for a nursing theory to be
adopted and utilized on a more comprehensive
scale within a healthcare facility thus empowering
all staff, not just nursing, to take part in
advancing the patients well-being. This has the
potential to increase meaning and purpose to the
work of the ancillary staff (Amendolair, 2012).
Education is imperative in making change.
Providing education on caring and caring
behaviors for all hospital staff, on an ongoing
basis is necessary in order to change the culture
of the institution. Setting clear expectations and
providing reinforcement of these concepts should
be considered from the beginning, starting
through the hiring and orientation process, to
periodic in-services and annual reviews. This
strengthening could affect the change needed to
have a positive impact on the work environment,
nurse and patient satisfaction, as well as positive
patient outcomes (Winsett & Hauck, 2011).

The Affordable Care Act (ACA), for many
institutions, may be considered a fiscal wake-up
call. Patient satisfaction rates are going to
be scrutinized more closely to calculate
reimbursement rates (Nissley, 2012); therefore
institutions will be looking for ways to improve
those scores.
Based on the findings, a caring-based
approach, across departmental boundaries,
could be considered a viable option.
In summary, caring is a concept that is
experienced and felt by everyone. Patients within
a healthcare facility are typically in a vulnerable
state of health or illness and often times may be
scared and anxious. Being cared for and about
by every individual they encounter during their
stay helps make for a better patient experience
and better satisfaction levels.
References
Amendolair, D. (2012). Caring behaviors and
job satisfaction. Journal of Nursing
Administration, 42(1), 34-49.
Baird, K. (2013, May 6). Trust: At the core of the
patient experience. Beckers Hospital Review.
Retrieved at www.beckershospitalreview.com/
hospital-management-administration/trust-at-
the-core-of-the-patient-experience.html
Baldursdottir, G., & Jonsdotttir, H. (2002). The
importance of nurse caring behaviors as
perceived by patients receiving care at an
emergency department. Heart & Lung, 31(1),
67-75.
Bent, K. N., Burke, J. A., Eckman, A.,
Hottmann, T., McCabe, J., & Williams, R. N.
(2005). Being and creating caring change in
a healthcare system. International Journal for
Human Caring, 9(3), 20-25.
Cara, C. (2003). A pragmatic view of Jean
Watsons caring theory. International Journal
for Human Caring, 7(3), 51-61.
Dingman, S. K., Williams, M., Fosbinder, D.,
& Warnick, M. (1999). Implementing a caring
model to improve patient satisfaction. The
Journal of Nursing Administration, 29(12),
30-37.
Doyle, C., Reed, J., Woodcock, T., & Bell, D.
(2010). Understanding what matters to
patients: Identifying key patients perceptions
of quality. Journal of the Royal Society of
Medicine Short Reports, 1(3), 1-6.
doi:10.1258/shorts.2009.100028
Graber, D. R. (2009). Organizational and
individual perspectives on caring in hospitals.
Journal of Health & Human Services
Administration, 31, 517-537.
Green, A., & Davis, S. (2005). Toward a
predictive model of patient satisfaction with
nurse practitioner care. Journal of the
American Academy of Nurse Practitioners,
17, 139-148.
Utilizing a Caring-based Nursing Model in an Interdepartmental Setting to Improve Patient Satisfaction
Henderson, A., Van Eps, M. A., Pearson, K.,
James, C., Henderson, P., & Osborne, Y.
(2007). Caring for behaviours that indicate
to patients that nurses care about them.
Journal of Advanced Nursing, 60, 146-153.
Institute of Medicine of the National Academies.
(2010). The future of nursing leading change,
advancing health. Retrieved from www.iom.
edu/Reports/2010/The-Future-of-Nursing-
Leading-Change-Advancing-Health.aspx
J. D. Power and Associates. (2012,
September 4). Patient satisfaction influenced
more by hospital staff than by the hospital
facilities. Retrieved from www.jdpower.com/
content/press-release/vANCTZa/2012-
national-patient-experience-study.htm
Johansson, P., Oleni, M., & Fridlund, B. (2002).
Patient satisfaction with nursing care in the
context of health care: A literature study.
Scandinavian Journal of Caring Sciences,
16, 337-344.
Larrabee, J. H., Ostrow, C. L., Withrow, M. L.,
Janney, M. A., Hobbs Jr., G. R., & Burant, C.
(2004). Predictors of patient satisfaction with
inpatient hospital nursing care. Research in
Nursing & Health, 27, 254-268.
Liu, J. E., Mok, E., & Wong, T. (2006). Caring in
nursing: Investigating the meaning of caring
from the perspective of cancer patients in
Beijing, China. Journal of Clinical Nursing,
15, 188-196.
Nikic, D., Arandjelovic, M., Nikolic, M., &
Stankovic, A. (2008). Job satisfaction in
health care workers. ACTA Medica Medianae,
47(4), 9-12.
Nissley, E. L. (2012, January 9). Health care
reform measures could affect hospital
finances. Thetimes-tribune.com. Retrieved
from www.thetimes-tribune.com/news/health-
care-reform-measures-could-affect-hospital-
finances-1.1255058
Otani, K., Waterman, B., Faulkner, K. M.,
Boslaugh, S., Burroughs, T. E., &
Dunagan, W. C. (2009). Patient satisfaction:
Focusing on excellent. Journal of
Healthcare Management, 54, 93-103.
Pross, E., Hilton, N., Boykin, A., & Thomas, C.
(2011). The dance of caring persons:
Transform your organization through caring
values. Nursing Management, 42(10), 25-30.
doi:10.1097/01.NUMA.0000405223.39798.e1
Schmidt, L. A. (2004). Patients perceptions of
nurse staffing, nursing care, adverse events,
and overall satisfaction with the hospital
experience. Nursing Economics, 22, 295-306.
Sofaer, S., & Friminger, K. (2005). Patient
perceptions of the quality of health services.
Annual Review of Public Health, 26, 513-559.
doi:10.1146/annurev.publhealth.25.05050
Stanowski, A. C. (2009). Influencing employees
attitudes and changing behaviors: A model
to improve patient satisfaction. Population
Health Management, 12(2), 57-59.
Suliman, W. A., Welmann, E., Omer, T., &
Thomas, L. (2009). Applying Watsons
nursing theory to assess patient perceptions
of being cared for in a multicultural
environment. Journal of Nursing Research,
17, 293-300.
Tonges, M., & Ray, J. (2011). Translating caring
theory into practice. Journal of Nursing
Administration, 41, 374-381.
Watson, J. (2009a). Caring science and human
caring theory: Transforming personal and
professional practices of nursing and health
care. Journal of Health & Human Services,
31, 466-482.
Watson, J. (2009b). Assessing and measuring
caring in nursing and health sciences.
New York, NY: Springer.
Wilson, A., Whitaker, N., & Whitford, D. (2012,
May 31). Rising to the challenge of health
care reform with entrepreneurial and
intrapreneurial nursing initiatives. Online
Journal of Issues in Nursing, 17(2).
doi:10.3912/OJIN.Vol17No02Man05
Winsett, R. P., & Hauck, S. (2011). Implementing
relationship-based care. Journal of Nursing
Administration, 41, 285-290.
Yeakel, S., Maljanian, R., Bohannon, R. W.,
& Coulombe, K. H. (2003). Nurse caring
behaviors and patient satisfaction:
Improvement after a multifaceted staff
intervention. Journal of Nursing
Administration, 33, 434-436.
Author Note
Pamela B. Dudkiewicz, DNP, FNP-BC,
AOCNP is an Advanced Registered Nurse
Practitioner, Department of Hematology/
Oncology at University of Miami Sylvester
Comprehensive Cancer Center, Miami, Florida.
Correspondence concerning this article
should be addressed to Dr. Pamela B.
Dudkiewicz, 1475 NW 12 Avenue, Suite 3400,
Miami, FL 33136 USA. Electronic mail may be
sent via Internet to pdudkiewicz@med.miami.edu
2014, Vol. 18, No. 4 33
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